Self‐esteem and learning dynamics in nursing students: An existential‐phenomenological study

Abstract

Aim

To describe nursing student self‐esteem changes over time and its impacts on learning strategies.

Design

Existential phenomenology.

Methods

Interviews were conducted in Spring 2018 in a purposive sample of 39 nursing students, exploring events critical to self‐esteem and their impacts. Transcriptions were analysed descriptively and interpretatively to decipher the process that links self‐esteem, events and learning behaviour.

Results

What led to self‐esteem changes were “relationships with nurses during internships” and “receiving evaluations.” The students interpreted events and drew conclusions about their aptitude for nursing, which in turn prompted proactive or defensive learning behaviours. Their interpretations both depended on their self‐esteem and impacted it, in a vicious or virtuous circle. Exploring self‐esteem allows a better understanding of the importance of students' relationships with nursing teams, and of some of their defensive behaviours. Understanding the role of nursing student self‐esteem in the learning process could help improve student well‐being and competence.

1. INTRODUCTION

This study was motivated by two findings across the globe: (1) nursing student self‐esteem declines during undergraduate education and (2) students have difficulty developing clinical competence. Many nursing students are assessed (Brown & Crookes, 2016), or assess themselves (Milisen et al., 2010), as not sufficiently competent. While self‐esteem may have an influence on efforts and learning strategies aimed at developing competence (Covington, 2000; Shavelson et al., 1976), little is known about how such influence operates.

2. BACKGROUND

Self‐esteem is defined as the emotional reaction to the difference between the actual self and the ideal self (Guindon, 2010). Depending on the approach, that assessment can involve only one dimension (value or competence), both dimensions (value and competence) or numerous dimensions – for example, the academic, familial or physical domains (Nader‐Grosbois & Fiasse, 2016).

In a two‐dimension approach (Mruk, 2013), worthiness is the feeling of having personal value, which comes from past experience of inclusion and of living in accordance with important values. Competence is the feeling of being able to overcome challenges, which comes from past experience of success. Since self‐esteem depends on competence and worthiness, a person must possess enough of both to have the solid, healthy self‐esteem necessary for good psychological and behavioural outcomes. An imbalance in these dimensions can lead to defensive self‐esteem, where the person places greater – sometimes excessive – importance on acceptance or success. Self‐esteem must be managed during the whole life and can change following critical events that Mruk calls “self‐esteem moments.” These are very stressful situations involving recurring evaluations and integration into new social groups – situations that nursing students experience often.

Studies have found self‐esteem to be medium or low in nursing students, and it may even decline in the course of nursing education (Randle, 2003b), but there are inconsistencies in the research findings (Valizadeh, Zamanzadeh, Gargari, et al., 2016). There are very few qualitative studies about nursing student self‐esteem. It is related to the sense of worth they derive from being a nursing student, their perceived level of professionalism and the degree of socialization in the profession (Zamanzadeh et al., 2016). It results from the balance between pressure and protective factors (Valizadeh, Zamanzadeh, Badri Gargari, et al., 2016), and its decline might be explained by bullying during the internship (Randle, 2003a). Self‐esteem affects the professionalization process of nursing students, and their professional behaviour (Randle, 2003a; Valizadeh, Zamanzadeh, Gargari, et al., 2016). Self‐esteem is also an important issue for nurses, as it influences the well‐being and mental health of people (Mruk, 2013) and, about nurses, affects the quality of their care (Arthur & Randle, 2007) and enhances their professional skills (Burnard et al., 2001; Randle, 2001). It also affects the career identity of graduating nursing students (Min et al., 2021). It is thus important to consider the self‐esteem issue as soon as the education.

Education aims to form competent nurses, with a good level of well‐being and the ability and motivation to pursue their development through continuous learning. Nursing competence leads to public protection, personal satisfaction of nurses and intra‐ and interprofessional dialogue (Charette et al., 2014). A gap is often described between education and clinical skills (Bennett et al., 2017) and Belgian students see themselves as not competent enough (Milisen et al., 2010).

A competent professional masters disciplinary contents, skills and more complex capacities, but also transverse resources, among others affective ones; those resources must be adequately mobilized in the situation (Jonnaert, 2009). Nursing students must develop those resources via theoretical and practical education, and mobilize them during clinical placements. But the courses and placements are not sufficient to develop competence; an accompanied reflexion is essential (Benner, 1984), and a personal effort is required, to adopt the needed learning behaviours. This effort depends on academic motivation (Rafii et al., 2019), which is affected by various personal and educational factors. Perceived performance is related to grit, a non‐cognitive trait keeping an individual on task for a long period, even under difficult circumstances (Terry & Peck, 2020). An affective dimension is therefore at work when considering the learning behaviours needed to develop competence.

The scientific literature has paid scant attention to the influence of self‐esteem on learning behaviour. Self‐esteem affects motivation and functional behaviour in general (Guindon, 2010), and has been described as an influential factor in school‐age children (Shavelson et al., 1976). Inefficient learning behaviours can be a way to protect low or defensive self‐esteem (Covington, 2000; Mruk, 2013), and external feedback may be sought to confirm good or bad self‐views, rather than to improve (Bosson & Swann, 1999). Although the relationship between self‐esteem and achievement, when present, is weak (Baumeister et al., 2003), self‐esteem can indirectly affect achievement through the intermediary of learning approaches – that is, deep/surface processing and effort – in university students (Román et al., 2008), and could influence initiative‐taking and persistence after failure (Baumeister et al., 2003; Dancot et al., 2021). In nursing students, self‐esteem is related to critical thinking (Suliman & Halabi, 2007), which is an important educational outcome and a prerequisite for the expression of competence (Lechasseur et al., 2011). But the relationship between self‐esteem and learning behaviour has not yet been studied specifically in nursing students.

Therefore, the issue of nursing student self‐esteem and its link with learning to warrant further research. The aim of this study was to explore nursing students lived experience of self‐esteem, how and why it changes over time and its links with student learning behaviour.

3. THE STUDY

3.1. Context

This paper reports one part of a larger longitudinal mixed methods study that follows nursing students from their first to the fourth year of study to understand how their self‐esteem changes over time and the relationship between self‐esteem and clinical competence development. Four out of the 16 vocational colleges offering a Bachelor's degree in nursing in French‐speaking Belgium were invited to participate in the study, which used purposive sampling based on geographical, network, size and institutional criteria yielding maximum diversity (Dancot et al., 2021). A cohort of 815 first‐ and second‐year students was assembled in October 2017 using accidental sampling (attending class) and followed annually with quantitative and qualitative data collection. Quantitative data included sociodemographic information, self‐esteem assessment and academic performance. Interviews could be agreed to or refused in the questionnaire. The qualitative component of the study's first year is reported here.

3.2. Design

The study used an existential‐phenomenological design inspired by Merleau‐Ponty (Thomas & Pollio, 2002). This design fits well with nursing research and the exploration of complex affective experiences in context, with an intention to understand the participants' experience and their interpretation of them (Thomas, 2005).

3.3. Method

3.3.1. Participants

Sixty of the volunteers from the quantitative cohort were invited to participate in the qualitative phase via sequential sampling (Creswell, 2009). A purposive sample was constituted to yield maximum diversity in terms of self‐esteem profile obtained from quantitative data, age, gender, study year, academic performance (if a non‐first‐year student) and institution. Thirteen students refused to participate, 12 of them due to time restrictions. Six accepted but did not come to the appointment. Forty‐one of those students participated in the interview process, which took place from February to May 2018. One student lied when compared to the quantitative data, and another admitted that she participated to get advice about her self‐esteem problem; neither of those interviews was included in the analysis.

3.3.2. Data collection

We conducted semi‐structured interviews with the volunteers during non‐internship periods to avoid any recent “sensitive clinical situations.” Appointments were made based on participant availability. Interviews lasted approximately 1 hr and were recorded and transcribed in their entirety. They were conducted in a single room with no one else present and no possible interruptions by members of the teaching staff. The students had not met the interviewer previously.

The interviews were designed to give an understanding of the participant's experience. They focused on the student's motivation, on their ideal self and actual self (which they indicated on a visual scale), and on the source and effect of any discrepancy between these two, whether it is programme events or external factors. The participants were asked to describe each event and to interpret its effect on their self‐esteem and on their learning or professional behaviour; each experience was discussed in detail (Thomas & Pollio, 2002). The guide also asked the participants about the overall impact of their education on their self‐esteem, their motivations for agreeing to participate and the interview experience itself.

3.4. Analysis

The data were analysed in two phases, descriptive and interpretive, as described in Table 1. After transcription, each interview was read multiple times to identify themes from the interview guide and emerging themes. The content analysis primarily used metaphors, similes, analogy, irony and rhetoric, and secondarily recurrence or commonalities across interviews to identify themes and subthemes (Thomas & Pollio, 2002). Themes and subthemes were coded in NVivo 12.

TABLE 1.

Content analysis process

Level of analysis	Sources used for analysis	Type of analysis unit	Example	Verbatim and source (participant pseudonym)
Phase 1: Descriptive	Study objective	Pre‐defined rubrics (classification function)	Internship	To see that the team doesn't like me, for example. (Ruth)
	2 Interview transcriptions Data immersion Labelling Phenomenological reduction	Emerging themes (descriptive function) → Self‐esteem critical events	Relationship with nurses	A nurse who answers me, who takes the time for me, it influences my self‐esteem, and very positively, because you tell yourself that you are not just a student who is there. We're also there to learn, and these people who give us time to learn, and who give us their time to learn, it's nice. We tell ourselves that we are not ‐ excuse the term ‐ little shits, because sometimes we are told that we are a bit like that. […] The last team really trusted me a lot. That was really good for my self‐esteem. Because I soon realized that they let me do things on my own, and I heard nurses I got on well with saying “oh well, we can let her go on her own, she works well.” And they let me do things on my own, and in the end, you feel even better, because you say to yourself “if they trust you, it's because you don't do just anything.” (Betty)
			Receiving marks or feedback	It's still a big disappointment, because I really worked a lot during my two months of holidays, and I didn't pass all my exams. It affects my self‐esteem, because in a society like this one, you have to succeed. I think that these marks can have a very negative impact on people. (Laura)
Phase 2: Interpretive	3 Themes coded in NVivo Progressive refinement of themes and arborescence Choice of themes relevant to the process of self‐esteem evolution and the links with learning Confirmation by a research associate and by the expert's team	Emerging conceptual categories of thematic structure	Yo‐yoing	There are times during the year when our self‐esteem is at its lowest. When we receive the results of an exam, when we see that we failed some when we thought we had passed, it lowers our self‐esteem. Now, knowing that I have passed my internship, that boosts my self‐esteem. Knowing that I failed my internship report lowers my self‐esteem. (Sharon)
			Causal attribution	Because I'm being judged for something I did wrong, when in fact it's not my mistake. I thought I was doing the right thing, since that's what we studied, and in fact I feel a negative judgement, but to which I can't really do anything. So that's annoying, because I don't want her to say to herself, she's not doing that well. It's more like, we didn't study it well. (Deborah)
			Being cut out to be a nurse	It's not easy, because when we see, during a training course, that we are not what we would like to be, or that we think we are good but that we are evaluated and that we are told that it's not great, it calls us into question, yes. Above all, “do I deserve to be a nurse, is that my place?” We question ourselves a lot. (Jennifer)
	4Literature Experts Return to interview transcriptions	Consolidated thematic structure and process description (modelling function)	Self‐esteem moment Yo‐yoing self‐esteem Adaptation strategy Perceived consequences	Self‐esteem moment → Yo‐yoing → Adaptative strategy: Causal attribution Comparison with peers Comparison with previous experiences → Perceived consequences: To be cut out for that (or not) Motivation → Consequences for learning behaviour

Data from each subtheme were condensed into a nomothetic description containing structured data, verbatims, so that we could describe experiential patterns in diverse situations (Thomas & Pollio, 2002). This descriptive analysis, guided by our study objective and by the emerging themes from the interviews, helped us identify critical incidents to self‐esteem.

Our interpretive analysis then helped us identify a process linking those events to learning behaviour and to develop the thematic structure (Thomas & Pollio, 2002). The themes and subthemes used for subsequent modelling were chosen based on (1) the intensity, in valence and duration, of their impact on student self‐esteem or behaviour; (2) their frequency and (3) their ability to shed light on the research question. The processes were progressively described by re‐reading the interview transcriptions, consulting the theoretical and empirical literature, and discussing with experts.

3.5. Validity, reliability and rigour

Criteria proposed for existential phenomenology are reliability, validity, generalizability and the “unconscious.” Of course, these criteria have not the same definition in qualitative research as they have in quantitative methodologies (Thomas & Pollio, 2002).

The interview guide was reviewed by experts in pedagogy, psychology and sociology to promote validity. The principal investigator explored her pre‐conceptions about nursing student self‐esteem beforehand and used them to look for conflicting clues during the analysis; there was an ongoing process of bracketing. The interview questions were descriptive, leading to the reporting of the lived experience and without analysis of causal factors so that the phenomenon could be fully described in the first‐person experiential world, including part of the “unconscious,” without recourse to theoretical mechanisms.

To obtain a broad view of the phenomenon that ensures reliability and generalizability, we used the criteria described by Morse for data saturation (Morse, 1995, 2015), that is, the number of participants and the depth of the interviews yielded a comprehensive view of the scope; the themes and subthemes gave a comprehensive view of the topic and of all aspects of the phenomenon being explored; there was sufficient replication in the data from a large and diverse sample; all of the data were given equal consideration, with variation valued over quantity; and “negative case” perspectives were explored and explained; all of this was done by theoretical sampling.

During the analysis process, discussions with experts from diverse backgrounds (clinical psychiatry, sociology, teaching and qualitative research) helped ensure reliability and acted as an interpretative research group ersatz. The themes were validated by the research associate who conducted some of the interviews and by experts to achieve a sort of triangulation. Interpretative phenomenology does not imply double coding or participant agreement after interpretation (Allen, 1995); feedback of participants were not asked in order not to influence the following interviews of the longitudinal research.

Findings were presented to nursing teachers and students and “validated” by them as reflecting and enlightening their experiences.

3.6. Ethics

This study was approved by an academic ethics committee (Comité d’Éthique Hospitalo‐Facultaire Universitaire de Liège 707) and assigned reference no. 2017/233.

Schools and participants were given information about the study and about the participants' rights and were asked to sign an informed consent form. The decision to participate or not had no impact on students' educational support or assessment. The data were not used to draw comparisons between identified institutions.

Data were anonymized during transcription. Interviews were conducted by a research associate at the principal investigator's institution. Nominative data are stored in a secure location and will be destroyed once the research and publication process is over. Data protection and privacy comply with General Data Protection Regulation principles (UE2016/679).

4. RESULTS

The 39 participants included 32 females and 7 males between the ages of 18–44 years, with a median age of 20 years (19–21); 26 were first‐year students, including five repeating students, and 13 were second‐year students. Eleven students had a high self‐esteem profile and 15 had a low self‐esteem profile; the other 13 students had a defensive self‐esteem profile based on acceptance (6) or success (7) following the model used in the quantitative part (Mruk, 2013). The complete characteristics of participants, referred to by the pseudonym, are shown in Table 2. Descriptive categories and themes are described in Table 3. From them, we identified self‐esteem moments and we led an interpretative analysis leading to identify processes of self‐esteem/learning dynamics. All participant quotes were translated from French.

TABLE 2.

Description of participants

Pseudonym	School	Self‐esteem level (16–80) Mean: 50.42 ± 9.09 + profile (High/defensive based on acceptance/defensive based on success/low)	State anxiety (20–80) Mean 59.43 ± 11.54	Age Median 20 (19–21)	Study year
Nancy	3	65 – High	25	21	2
Laura	1	61 – High	36	19	1
William	2	60 – High	29	20	1
Robert	2	59 – High	24	22	2
Shirley	2	58 – High	48	49	1
Sandra	1	57 – High	26	19	2
Brenda	2	57 – High	23	20	2
Melissa	2	56 – High	35	23	1
Elizabeth	4	55 – High	49	19	1
Christopher	3	54 – High	27	31	2
John	2	54 – Def. acceptance	33	22	1
Michael	2	52 – Def. acceptance	28	18	1
Steve	4	50 – High	56	44	1
Virginia	2	49 – Def. acceptance	42	22	2
Jessica	2	49 – Def. acceptance	35	19	1
Deborah	2	48 – Def. success	45	20	2
Susan	4	48 – Def. success	49	21	1 repeat
Sarah	1	46 – Def. acceptance	51	17	1
Amy	2	46 – Def. success	62	20	2
Mary	4	44 – Def. acceptance	47	20	1 repeat
Jennifer	4	43 – Def. success	52	21	1 repeat
Kimberly	1	43 – Low	NA	39	1
Carol	1	42 – Def. success	43	19	1
Michelle	1	42 – Def. success	54	19	1
Patricia	4	41 – Low	34	19	1 repeat
Sharon	1	40 – Low	51	19	1
Barbara	4	39 – Low	36	20	1
Dorothy	3	38 – Low	71	21	1
Betty	3	38 – Low	53	19	2
Helen	1	36 – Low	27	18	1
Ruth	1	36 – Low	58	19	1
Margaret	3	35 – Low	51	18	2
Anna	2	35 – Low	59	18	1
Angela	2	34 – Low	63	21	2
James	1	34 – Def. success	28	29	1
Cynthia	2	33 – Low	72	19	2
Lisa	3	32 – Low	59	18	1
Karen	3	31 – Low	56	20	2
Linda	4	26 – Low	57	21	1 repeat

TABLE 3.

Categories and themes

Category	Theme	Verbatim (participant)
Self‐esteem moment	Relationship with nurses during the internship	When we do something and a nurse says “thank you”, we're happy, we helped, she’s happy with us. (Angela)
		I think she took a bit of a dislike to me, I don’'t know why, she considered me like, really, I’m sorry, but she considered me like shit, I don't even know why, I hadn't done anything and that’s it. She gave me little tasks, I was doing parameters all day long, well, I know how to do the parameters very well, but I needed to learn something else and yes, at that course, it really went down. I couldn't ask any questions, otherwise they would turn me down… […] It's really the team, if the team treats us badly or whatever, there's almost nothing to hold on to, it's really difficult. (Cynthia)
	Receiving marks/feedback	Telling myself that I succeeded the first time around, that I'm in second year when I'm only 19 years old, that's what I'm often told, I'm happy, I’ve done well in my studies. (Sandra)
		The sadness, the disappointment, I was a little ashamed of myself too, of the regret of not having worked enough, or not having worked more… (Ruth)
Reaction	Yo‐yoing	It is the roller coaster. (William)
Adaptive strategies	Causal attribution	I study well the day before, when I know that the teacher will come, according to what I have observed in the setting, the gestures they usually do; I know that every time we have them, so… I review my gestures, and, in the end, I am quite well prepared for my evaluations, so it goes well. (Sandra)
		Stomach, I knew, but she asked me for the pylorus, the handle, really the specific things, we don't know how to do that. If someone had told me, prepare such and such a thing, I would have done it, I would have looked less stupid, it's mostly that. I do stupidly my stomach, and she says to me, haven't you forgotten things? (Margaret)
	Comparison with peers	When I say that I have great distinctions, the teacher told the other students that there was one student who had had great dis’, something she never wore, but that this student had something special that made her a nurse. She was talking about me. Because I'm the only one to have had big dis’, and there were five of us who were evaluated by that teacher. So, it could only have been me, so it's really gratifying to think that a teacher thought that to the point of going and talking to the others about it, to the point of giving me great dis’ when she never gave any… (Nancy)
		When you hear that, for such an exam, there is a 5% pass rate, it's a bit discouraging to study or even to go to the course. (Michelle)
	Remembering previous experiences	That's the experience, I was in fourth year. We have lived through a lot of situations before that may have been a little difficult or not, which I may or may not have taken for myself, but here I really did take as far back as possible, and when I hear other people's stories as well, that things are not going well in their department and all that I think that in the all the services it can happen like this, it's not especially for me, and then I analyzed a little bit why she didn't like students, because she was scared, because she wanted to be there for a blood test or things like that in fourth year we know how to do… (Robert)
		I confess that I used this internship, and the team as a whole when I was not at all motivated to continue. I said to myself: “Well, come on, they told me that I was really good, you have to put it in perspective, you only have four weeks. Four weeks in all of your studies and then your career at the final is nothing.” I told myself it's time to go, and that's what made me served. (John)
Perceived consequences	Being cut out to be a nurse	If the internship had gone badly, my exams had already not gone very well, then I would have said to myself, I'm not cut out for this. (Patricia)
		It was mostly during my internship. I noticed that, for example with my friends, there were some who didn't have the trick to be with the patients, to be attentive, to respect the instructions in terms of modesty and all that. I integrated them directly, and I knew what I had to do, I knew that I had to respect the person. I think it's already a good point to say that we can do it. (Elizabeth)
	Motivation	I tell myself that the big first exam, I got it, I tell myself, I have the means. It really made me say to myself, you've worked, you've got it, that's good, keep it up, you're going to work, you're going to get it. I was super happy, it really motivated me to succeed. I understood a little bit how I had to work and everything. (Patricia)
		And when the results appeared, I was sad, and at the same time, I think it had an influence afterwards, because I was less involved, I had a loss of motivation, that's it. (Mary)
Learning behaviour	Proactive	I realized that with a good team like that, we were much more, how can I explain it, much more, already, we are much more dynamic, so you can feel it. But we're much more in the perspective of doing well, because behind us, there's someone who's going to ask us, did it go well? And that makes you really want to do better. (Jennifer)
	Defensive	The training course where I was, which went really badly, it was also after a week where I tried to show that I knew how to do things and that people hadn't noticed, I closed myself off a bit in the role of care assistant where I said to myself, “there you go.” And in the end, the last week of the placement, I didn't even ask for any more techniques even though I hadn't done any since the beginning of the placement, because that's how I was seen. (Brenda)

4.1. Self‐esteem moments during the first years of nursing education

At the beginning of the interview, participants were asked why they had placed their “actual self” line where they had, and to give some explanation. The first events they talked about were considered critical moments for their self‐esteem. To check our understanding, at the end of the interview we asked them to identify the primary factor influencing their self‐esteem. These data were used to identify two major “self‐esteem moments” (Mruk, 2013): relationships with nurses and evaluations.

4.1.1. Relationship with nurses during internships

The nursing team had both positive and negative impacts on student self‐esteem. Because the internship represented reality, the team had a huge influence in either case.

It's the reality, you're not sitting in a chair behind a desk and just learning things like that, which when you're in the chair don't seem important to you, but you apply everything you've seen or learned. (Robert)

Two dimensions of self‐esteem were affected. Value, or worthiness, was influenced by the nurses' attitude towards the student, how well‐integrated the student was on the team, and the student's assigned role during the clinical training period. Competence was affected by statements about the student's competence or ability to be a nurse. While the statements need not have been positive, if they were not positive, they had to be constructive, so that the student learned how to be more competent. Combining the two dimensions offers to be a future member of the team were always a important source of self‐esteem.

There were many positive experiences, but the negative ones had a deep and lasting impact.

I really had a hard time with it, but I made sure that I worked with other nurses, who told me that I worked well […]. But it's true that I had a hard time, I questioned myself a bit, I said to myself ‘Am I going to make it, how will it go next year?’ […] during the whole internship. Because he said those things to me on the second or third day of the course, so afterwards I was stressed all the time. (Karen)

Negative experiences also had a collective impact, since many of the participants referred to them without having experienced them personally. This demonstrates the stressful nature of the internship and, in particular, of the students' relationships with the nurses.

During the clinical training periods, I know girls who hated that period, because nurses were really awful to them. Actually, I've already heard that to be a nursing student, you sometimes have to grin and bear it. And I think it has a lot to do with self‐esteem […]. I think this is my biggest fear for my clinical periods, the team I'll be placed on. (Carol)

Students also identified other actors who had an impact on their self‐esteem, including patients (whose feedback always strongly reinforced their self‐esteem), teachers, peers, family and friends.

In general, when talking about how their self‐esteem changed over time, they often said that it increased during the first 2 years of nursing education. About the nursing team, they explained that improvement by their sense of gradually finding their place, of being useful, of being capable and in some rarer cases, of asserting themselves.

4.1.2. Receiving marks/feedback

Marks on exams or clinical evaluations strongly influenced self‐esteem at the beginning of the nursing program. Most often, success improved self‐esteem and failure diminished it. We found signs of this impact primarily in the younger students; the more mature students we interviewed seemed to have more stable self‐esteem and were less influenced by education.

Because education is still a big part of our life, and so it's still a big part of us. So, I think it plays a role. (Linda)

Passing exams or internships mainly influenced the dimension of competence and the idea that they could succeed in nursing education.

What boosts my self‐esteem is my exam experience, in January, I know I can pass. (Helen)

With my teacher from this placement, I see myself more positively after this feedback, because she gave me positive feedback. […] And so, because she felt that she had confidence in me, that she could see that I handled things easily, it's clear that I have more confidence in myself after having those exchanges with her. Because, really, I know that I did the right thing and that I am able to. (Deborah)

Failure strongly impacted self‐esteem; it was sometimes described as a shock, and as eliciting feelings of shame. In some cases, however, this first negative impact led to a redoubled effort to learn in the longer term. To overcome failure, students needed support from their relatives and friends, but would also have appreciated support from their teachers.

Last year, I still had a setback. Even for my parents, I told myself, since I don't live near here, I'm in a student room, my parents pay for all that. What's more, I have an older brother who's in seventh grade law, who's doing really well. I told myself, what will people say about me? (Carol)

I think that all students, after their first exam in university, in high school, it influences their view of themselves, and… there you go. Every time I think about it, it makes me feel a bit down, you might say. I've lost a bit of my self‐esteem, though. (Ruth)

Then afterwards I say to myself: ‘No, you didn’t do all this for nothing, you didn't repeat a year for nothing, you stay there, you finish, you go all the way’. (Virginia)

A minority of participants felt that elements other than marks were more important for their self‐esteem – specifically, their experiences with patients or what they felt inside, like internal feedback.

But I prefer to have been happy myself with the relationship I had with the training supervisor and with my patient, and that's what counts for me, and that's what increases my self‐esteem, in any case. (Laura)

4.2. Self‐esteem/learning dynamics

Whenever participants identified an event affecting their self‐esteem, they were asked to say more about how that event may have affected their way of being or thinking and their learning behaviour. The following process emerged: impact on self‐esteem → adaptive strategies → perceived consequences → impact on learning behaviour. Since the nursing students had many self‐esteem moments, they described their self‐esteem and feelings as “yo‐yoing.”

4.2.1. Adaptive strategies

Students used certain strategies to cope with such feelings, including causal attribution, comparison with peers and remembering previous experiences. Students started by analysing whether events were due to their merit or their fault, or not. At the same time, they assessed their ability to manage the situation and change it, and the probability that they would experience that event often or not. This is the process of causal attribution, which is a “cognitive process that consists of searching for causes that may explain the occurrence of events” (Bruchon‐Schweitzer, 2002, p. 247). Causal attribution is an explanation that is created about a specific situation, including interactions between the individual and the context. It draws a conclusion about internal or external causality, (un)controllability with internal and/or external resources, and (in)stability.

I was afraid. Especially because I was at a big university hospital, quite big, many floors, quite complicated. They don't necessarily give us the necessary information, they don't tell us how to get there, they don't tell us how to pay, they don't tell us how we're going to eat, and so on. We are sent there as perfect little students, all ready, all prepared, when in fact we are not at all. (Sharon)

Interpretation depended on the students' appraisal of their personal resources, and therefore on their self‐esteem. For example, when facing a potentially threatening situation or a bad result, students with higher self‐esteem concluded that they had enough resources to cope, or that they could afford to fail without needing to protect their self‐esteem. Conversely, students with low self‐esteem felt they lacked the necessary resources and were unable to change the situation. Causal attribution varied over time, and with changes in self‐esteem.

Whereas before I would have said: ‘Anyway it’s all the same, they all behave the same way, they're all bad, if not worse’, then I would have given up, I would have said to myself: ‘Well, I'm not making any more effort’. But now I want to make the effort, to say to myself ‘Come on, I can be a really, really good nurse’. (Dorothy)

Students' interpretations depend not only on their self‐esteem but also on the situation. They compare themselves to their peers in the same situation or remember previous experiences. For the top students, comparing their performance to that of their peers enhances the positive effect. Sometimes success gives comfort long afterward, when the person is having problems. But for some students its effect is short‐lived.

Often, I don't know, I'm not going to say that I have good grades, but I'm above average, but despite that I still don't have confidence. […] after that, I go back to the way I was before, I realize that I'm still the same as before and I go back to my ‘I'm not good enough yet’ thing. (Angela)

Interpreting an unpleasant situation and not depending on them has a protective effect on self‐esteem, especially when receiving non‐constructive feedback or having a difficult relationship with members of the nursing team. The impact of nurses' behaviour on students' self‐esteem depends on how students interpret it. Students consciously expressed two examples of this: exaggeration or distancing.

What professionals think of my actions, my techniques, and my care is very important, and I know that I automatically take it personally when I am told that something is not right, I have the impression that I was doing everything wrong, that I really sucked … Well, it's not really that I don't accept criticism, it's just that I would like it to go well right away. (Betty)

You have to understand, I put myself in their shoes too, and later, maybe I'll be like them, to say ‘the student will do this, will do that, I don't have the time’ […] to say to myself, ‘Come on, it's not just me, it's because I'm a student, it's because they have something else going on’. (Dorothy)

4.2.2. Perceived consequences

Events, and students' interpretation of their own responsibility for them, led them to conclude that they were cut out to be a nurse and could succeed, or not, and this affected their motivation.

I feel like if I fail the training courses, nursing is not for me. Because it's the field, it's the practice. (Betty)

Students felt they could succeed in some domains – particularly relational ones. This encouraged them to say they could be a nurse. In other domains, like knowledge and technical skills, students sometimes fell far short of their learning objectives and did not feel they could bridge the gap. But they also acknowledged that developing competence takes time and that they were encouraged by their progress.

I feel like if I fail the training courses, nursing is not for me. Because it's the field, it's the practice. (Betty)

For what we studied I think I am competent. […]During the internship, there was no point at which I said to myself: ‘No, that I really can't do”, regarding what I studied, in any case. I knew how to apply all the techniques we studied, and there was no problem with that’. (Michael)

I can see that I still have a lot of work to do… I can't do it yet, but that's what I'm here for, I'm here to learn, so I don't let it throw me off balance. (Lisa)

Some students described the reciprocal relationship between self‐esteem and the feeling of being capable.

This feeling of being competent affects your self‐esteem. You feel more comfortable and better in your boots. (Michael)

I had this during my internship: since I don't really have self‐esteem or self‐confidence, I sometimes get caught up in stress and, as a result, I lose my ability, I can't do the technique. I know it well but ‘it won't come out’. And so, I tell myself that if I work on this within myself, I will be better at technical acts. (Sandra)

Students equated competence with knowing the course material, performing techniques correctly, knowing what to do in a given situation, being well‐organized, considering other stakeholders, establishing a relationship and offering empathy along with technical care. They assessed their ability to be a nurse mainly through internships and feedback from nurses, teachers, patients and examination marks. The feeling of competence depended on success or failure not only for the placement in general but also for more specific aspects such as particular techniques and situations. Some equated competence with the ability to do well in their studies. Few of them drew a distinction between knowledge and competence in situations, which can be influenced by contextual factors. Those who equated competence with a technical act or other very limited facts tended to experience a yo‐yo effect – successfully performing one act heightened their self‐esteem, and failing at the next one diminished it. Since negative events tend to have a longer‐term impact, this was not good for their self‐esteem.

Many students felt they were entitled to make mistakes and had time to improve, even after graduation. But some did not feel it was alright to make mistakes – they wanted to be perfect immediately; others pointed out that nurses did not allow them to make mistakes, or expected them to have a different skill level than that which they were supposed to have achieved at that stage of their studies. Feeling that they had time to improve had a protective effect on their self‐esteem.

These events also influenced students' motivation. Internal causal attribution of success was a great source of motivation. This was especially true if the success was personally meaningful to the student, giving it intrinsic value.

I think that if I didn't succeed, maybe I would stop, but the fact that I know that I do well in my internships, that my patients really appreciate the way I am, that my teachers who come to supervise me during my internship say to me: ‘Stay as you are, it's fine’, I tell myself that I do. And then at home as soon as someone gets hurt, I'm the first to arrive with everything and then they realize that my way of doing things is very different from others, that my GP often says: ‘She will do it now that she knows how to do it’ and he also values that side of it because he knows that Dad might not do it and so, somehow, outside people are pushing. And I tell myself that I have to keep going because I am worth it, I am successful and so there may be a way that I can succeed in changing perhaps a mentality but it is a great success too. (Amy)

Failing marks had a motivating or demotivating effect, depending on whether they were seen as an incentive to improve or a verdict of inaptitude. Failing courses where the student worked hard or courses with a high failure rate was more demotivating.

4.2.3. Influence on learning behaviour

Students have a variety of experiences. Those experiences, and how students interpret them (which depends, among other things, on self‐esteem), can enhance or undermine their worthiness, or self‐liking and competence. In Figure 1, experiences are represented according to Mruk's two‐dimension approach (Mruk, 2013) which reflects well the dimensions potentially impacted by nursing education. Experiences can make students feel secure, challenged, and capable, motivating them to take risks, ask questions, take initiative, and prepare themselves. They then adopt proactive behaviours conducive not only to learning but also to more “self‐esteem‐enhancing” experiences.

FIGURE 1.

Self‐esteem/learning behaviour dynamics.

We went from ‘I'm stressed out by her presence, I'm doing a bit of everything’, to ‘Ah, finally, she's nice, I want her to be proud’, and so it got much better as time went on. And I think the better I did things, the happier she was, and so on. A kind of virtuous circle. (Sarah)

Conversely, students can start feeling insecure, incapable and useless, causing them to adopt more defensive behaviours like withdrawal, silence, only doing simple procedures or self‐handicapping behaviour. Those behaviours lead to more experiences of failure or rejection, in a vicious circle.

Whenever I asked questions, it was never the right time, or there was something else to do, or I didn't have time. As a result, I never dared to turn to them. (Linda)

This vicious circle can even lead to dropout.

I decided to give up, not because it's actually too hard, but because it's too hard for me emotionally, so yes, it's actually too much to bear. (Virginia)

In Figure 1, self‐esteem is shown as a dotted path that can be high or low depending on previous experiences and social support but can also change in response to current experiences and support. The higher the self‐esteem, the more the interpretation tends towards good feelings and proactive behaviours. The reverse is also true. Because the participants described self‐esteem as fluctuating, the path is sinusoidal rather than linear.

5. DISCUSSION

The aims of this study were to better understand nursing student self‐esteem, how and why it changes over time and how it can affect student learning. We identified two self‐esteem moments during the first 2 years of nursing education, namely “relationship with nurses during internships” and “receiving marks/feedback.” We explored how such moments were interpreted by students. They described a process of adaptative strategies via a causal attribution, a comparison with peers and the remembering of previous experiences; that process leads to the conclusion of being cut out (or not) to be a nurse and a following (de)motivation. Finally, students adopted proactive or defensive learning behaviours.

The description of the lived experience of self‐esteem was consistent with the two‐dimension model of Mruk (Mruk, 2013). We noted that older students reported less impact because nursing school was less important than other aspects of their lives, which is consistent with Mruk's observation that self‐esteem moments depend on the importance the subject places on the situation (Mruk, 2013) and the widely accepted idea that self‐esteem is more stable in adults (Guindon, 2010).

5.1. Self‐esteem moments in nursing education

An important first self‐esteem moment was the relationship with the internship nursing team. This was expected, as this relationship has already been found to be a major self‐esteem influence factor (Randle, 2003b) and because clinical placements are a important source of stress for nursing students (King, 2019). Ineffective instructor‐student interaction was also identified as “pressure factors” affecting self‐esteem in Iranian nursing students (Valizadeh, Zamanzadeh, Badri Gargari, et al., 2016).

However, contrary to what Randle has reported, we found that the relationship with the nursing team can affect nursing student self‐esteem both positively and negatively, depending on the nurses' attitude and the student's interpretation of it. This might be explained not only by possible differences in school and care systems but also by differences in our methods. Randle collected her data during clinical placement periods, when the stories were “hot,” whereas we collected our data during non‐placement periods when students had time to gain perspective.

Relationships with nurses affected both worthiness and competence, because students experienced both acceptance/rejection and success/failure. The impact on self‐esteem was important, because nursing is an important domain for students and because clinical placements represent “reality,” this is, the students identified nurses as the best source of information about them as future nurses and about their professionalization process. Yet the impact on self‐esteem is greater when the experience involves a domain that is important to the subject (Mruk, 2013) and, for nursing students, when it gives them information about their level of professionalization and socialization (Zamanzadeh et al., 2016).

A second major self‐esteem moment was receiving marks on exams or internships. Randle (2003b) did not identify this as a critical moment, due perhaps to the fact that she collected data at a different time, as explained above. It might also be because we interviewed students during their first 2 years, when courses are a bigger part of nursing education. The first assignment is of special importance to students (Young, 2000) and feedback can harm self‐esteem (Mutch, 2003). Evaluations are success/failure experiences that influence the competence dimension of self‐esteem (Mruk, 2013). Low self‐efficacy relating to failures was also identified as a pressure factor affecting self‐esteem in Iranian nursing students and, on the other hand, knowledge acquisition as a protective factor (Valizadeh, Zamanzadeh, Badri Gargari, et al., 2016). We can suppose that receiving marks or feedback informed nursing students about similar elements.

Note that how an event affects self‐esteem depends on the student's interpretation of that event. The interpretation of these experiences and the effect on students' learning behaviour are discussed in the next section.

5.2. Self‐esteem/learning dynamics

Everything comes down to students' interpretation of who they are and what is happening, in a circular dynamic. First, students described a process of causal attribution. The various combinations of explanations had different consequences in terms of the participants' feelings and behaviour, and our observations were consistent with the theoretical description – that is, failures that are attributed to internal, unstable and controllable causes have a positive effect on adjustment (via problem‐centred and support‐seeking strategies), whereas failures that are attributed to external, stable and non‐controllable causes tend to result in distress and avoidance strategies (Bruchon‐Schweitzer, 2002). Failures explained in internal, global, stable and uncontrollable terms also lead to impaired performance and, if repeated, to feelings of incompetence and self‐deprecation or reduced self‐esteem (Bruchon‐Schweitzer, 2002).

Causal attribution influences self‐confidence: students who succeed and attribute their success to their own effort and abilities see themselves as more competent, or “cut out to be a nurse.” Conversely, an internally attributed failure can make them think they cannot do it, especially if they get no advice on how to improve.

This has an impact on motivation, which is what engages the subject in the task cognitively, emotionally and behaviourally. Motivation is influenced simultaneously by personal factors and by external factors related to the learning situation, the context and relationships with the people involved (Bourgeois, 2006). The motivation was found as having an effect on self‐esteem in Indonesian nursing students (Deviantony et al., 2021), where we showed that the effect of an event on self‐esteem can be prior to the effect on motivation.

Actually, we can explain both directions. Students described their initial motivation to be a nurse in connection to their previous experiences. That motivation was influenced by how they interpreted certain things that occurred during their nursing education, whether those things involved the students themselves (such as success or failure), the people they cared for (such as being thanked) or the nurses they encountered (whether or not those nurses were motivated by their profession). That general motivation is linked to self‐esteem issues (Mruk, 2013).

Students also described the more specific motivation for each task they encountered: a given course, an internship or a care procedure. That specific motivation depended on the student's interest in the task and in the results of the task, such as learning or feeling useful.

Since motivation impacts commitment to learning, it clearly has an impact on task performance and skill development. This impact on task‐specific motivation is coherent with the Self‐Determination Theory (Adams et al., 2017). This theory emphasizes that autonomy, competence and relatedness are students' basic psychological needs. A greater level of these three driving forces enables a person's automatic motivations and determines attitude and behaviour. Two of these psychological needs, competence and relatedness, are directly related to the two‐dimension conception of self‐esteem, explaining how their presence in the students, but also the opportunity of the context to more or less promote them, impacts students' motivation. It also explains why the relationship with mentors at clinical placement is related both to their self‐esteem and their motivation. At least, as motivation has a role in outcomes (Vallerand et al., 2008), these latest being more or less adaptative, it explains the circular dynamic we observed, since the resulting experiences in turn impact self‐esteem and motivation. Mruk's approach and his description of defensive self‐esteem also help explain why that dynamic can be circular. Self‐Determination Theory explains both the bright and dark sides of learning behaviours as outcomes of the interaction between students' basic psychological needs and the sources of need support or thwarting during education (Adams et al., 2017). The understanding of the effect of self‐esteem and the description of self‐esteem profiles (Mruk, 2013) allow further advance in our understanding of this internal process.

5.3. Educational implications

Our findings are the initial results from a longitudinal mixed methods study and, as such, must be confirmed, supplemented and nuanced. They do, however, suggest two possible avenues of action. Since students have a variety of experiences, some really difficult, we might consider how we can improve students' experiences during nursing education. Since their behaviour depends on how they interpret those experiences, another way might be to think about how we can support that process so that they enter a virtuous circle – or at least avoid a vicious circle. Interpretation will depend on the context and the student's personal characteristics and needs to be better understood.

In terms of student experiences, we might try to ensure that students experience enough moments of inclusion, both at school and during internships, and enough success. The students pointed out that getting a warm welcome, having a positive status as learners, being allowed to make mistakes, seeing their efforts valued and facing well‐calibrated challenges helped them feel accepted and successful. Meeting positive role models and seeing the profession valued at school, in their placement settings, and by society is also important to their self‐esteem (Zamanzadeh et al., 2016). Nursing schools should collaborate with internship places to improve the quality of the experience that students live during internships, and include the leadership and competencies needed to accompany nursing students in the curriculum.

In terms of how students interpret their experiences, we recommend that we – as teachers and as researchers – attempt to understand that process. We should value effective learning behaviours and good marks, and the development of competence and the capacity to be a nurse should be described as a comprehensive and gradual process. We could probably help students along in this process by teaching them how to manage their feelings – particularly students who exhibit low or defensive self‐esteem and/or ineffective, seemingly unmotivated, learning behaviour. This is especially important for aspiring nurses who experiment with very strong affective experiences during their curriculum and have to develop the capacity to manage them in themselves and in others.

5.4. Strengths and limitations of the study and future research

Our study shows the processes involved in the changes in self‐esteem and learning behaviour observed in nursing students. We have created a model for how an event becomes a self‐esteem moment and how this impacts learning.

And while qualitative research is never “generalizable,” this study looked at a large number of students selected with purposive sampling, and the data were both varied and recurrent enough to enlighten the phenomenon. Data analysis was triangulated with a research associate and a committee of experts from a variety of backgrounds. The principal investigator has a clinical and teaching background that has given her a broad understanding and the ability to read results from a range of different viewpoints. The findings were presented to teachers and student assemblies, allowing us to elicit their comments and interpretations. We therefore expect trustworthiness and transferability to similar situations. The study was, however, limited to first‐ and second‐year students.

Another potential limitation was selection bias since we only invited students attending classes and worked with volunteer participants.

We were unable to ask the participants to confirm our data analysis because this was the first part of a longitudinal study and we did not want to affect subsequent phases. We did, however, listen to the entire recorded interview again while reading the transcripts to ensure data integrity.

We were probably influenced by the theoretical model used for the quantitative part of our longitudinal study. However, we did not use it to conceive the interview guide nor to analyse the results. Once analysed, the findings fit well with the model that was used to structure the description of the phenomenon.

The next phase of our longitudinal study – or other more detailed qualitative studies – could help refine our model, which also needs to be confirmed by quantitative studies. Educational changes based on this model should be evaluated by measuring self‐esteem, learning behaviour and academic performance.

6. CONCLUSION

This paper adds to our understanding of the effect of nursing education on self‐esteem, and of the role played by nursing student self‐esteem in the learning process. Exploring that phenomenon could help improve nursing student well‐being and clinical competence.

Our findings show that the self‐esteem/learning dynamic is a circle that can be vicious or virtuous. We are beginning to understand the process driving this dynamic, which depends both on events experienced by students and how they are interpreted. If we want to break a vicious circle or promote a virtuous circle, we need to consider events and interpretations. Both influence the way students view themselves and their future profession, and the way they behave when learning. A two‐dimensional approach to self‐esteem allows a better understanding of what is impacting students and why their relationships with nursing teams are so important to them. Mruk's self‐esteem profiles also help explain some defensive behaviours that, while counterproductive to learning, are needed to protect student self‐esteem.

We must bolster student self‐esteem so that future nurses are not just competent, but also self‐confident and happy with who they are and the path they have chosen. That is, just as students need guidance in improving their professional thinking and action, they also need to be cared for in the same way they are taught to care for themselves and their patients.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

Dancot, J. , Pétré, B. , Voz, B. , Detroz, P. , Gagnayre, R. , Triffaux, J.‐M. , & Guillaume, M. (2023). Self‐esteem and learning dynamics in nursing students: An existential‐phenomenological study. Nursing Open, 10, 939–952. 10.1002/nop2.1361

DATA AVAILABILITY STATEMENT

Data available on request due to privacy/ethical restrictions